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Conductivity and Rythm in
Children
By
Awurum Prisca Oluchi
Rhthym and conduction
• Heart rhythm is its pace or beat while
Conduction is the progression of electrical
impulses through the heart which cause the
heart to beat. You can have a conduction
disorder without having an arrhythmia, but
some arrhythmias arise from conduction
disorders
Heart Rate
• In general, the younger and smaller the child,
the higher you would expect the heart rate to
be. A newborn routinely has heart rates up to
the 150s with no cause for concern. As we
age, the heart rate slows considerably.
Normal Heart Rates (Resting)1
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Age
Normal Range beats per min
Premature 120-170
0-3 months 100-150
3-6 months 90-120
6-12 months 80-120
1-3 years
70-110
3-6 years
65-110
6-12 years
60-95
Over age 12 55-85
Rhythm and conducitivity Disturbance
in children
Arrhythmia.
it could mean that the heart beats faster than
normal (tachycardia), very fast (flutter), fast and
with no regularity (fibrillation), slower than
normal (bradycardia), or that it has isolated early
beats (premature beats). While true arrhythmias
are not very common, when they do occur they
can be serious. On rare occasions they can cause
fainting or even heart failure. Fortunately, they
can be treated successfully so it’s important to
detect arrhythmias as early as possible
List of arrythmia
• Treatment not required
Sinus arrhythmia
Wandering atrial pacemaker
Isolated premature atrial contractions
Isolated premature ventricular contractions
First degree AV block
• Treatment is required
Supraventricular tachycardia
Ventricular tachycardia
Third degree AV block with symptoms
SINUS ARRHYTHMIA
• Most common irregularity of heart rhythm
seen in children
• Reflects healthy interaction between
autonomic respiratory and cardiac control
activity in CNS
• Heart rate increases during inspiration and
decreases during respiration
Wandering atrial pacemaker
Atrial pacemaker shifts from
sinus node to another atrial site
It can cause irregular rhythm
Isolated PAC’s
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Premature atrial contractions
Benign in absence of underlying heart dz
Common in newborn period
Early p wave, sometimes with different morphology
than a sinus p wave
• Can be either:
– Not conducted to ventricle, apparent pause
– Conducted to ventricle with aberrant or widened QRS
complex ( careful not to mix up with PVC’s)
Isolated PAC’s
Premature Ventricular Contractions (PVC’s)
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Not very commonly seen in children
Incidence of 0.3 to 2.2 %
Early, wide QRS complexes
T waves in opposite direction of QRS
Unifocal PVC’s are most encountered type
Bigeminy, sinus beat followed by PVC,
repeating as a pattern, also frequently seen
PVC’s
• If unifocal, disappear with exercise, and associated
with structurally and functionally normal heart, then
considered benign, no therapy needed
PVC’s evaluation
• 12 lead EKG, Echocardiogram
• Perhaps Holter monitoring
• Brief exercise in office to see if ectopy
suppressed or more frequent
• Multifocal or paired PVC’s more worrisome
• Medications usually not needed
• Advise patients to avoid caffeine and other
stimulants
First degree AV block
• Commonly seen (up to 6% normal neonates)
• PR interval is greater than upper limits of normal for
a given age
• PR interval is age and rate dependent
• 70-170 msec in newborns is normal
• 80-220 msec in young children and adults
• Generally does not cause bradycardia since AV
conduction remains intact
First degree AV block
• Diseases that can be associated with first
degree AV block: rheumatic fever, rubella,
mumps, hypothermia, cardiomyopathy,
electrolyte disturbances
Third degree AV block
• AKA complete heart block
• Most common cause of abnormal bradycardia
in infants and children
• Complete disassociation between P waves and
QRS complexes
Third degree AV block
• Can be congenital – in this case it is strongly
associated with maternal SLE
• Mom of an infant should be worked up
• Most common structural heart defect
associated is corrected transposition of great
vessels
Third degree AV block
• May be asymptomatic – follow clinically
• Slower the heart rate, and wide QRS escape
rhythms place into high risk group
• May need implantable pacemaker: significant
bradycardias, syncope, exercise intolerance,
ventricular dysrhythmias, or ventricular
arrhythmias, structural disease
• Possible acute treatment: isoproterenol
Supraventricular tachycardia
• Most common abnormal tachycardia seen in
pediatric practice
• Most common arrhythmia requiring treatment
in pediatric population
• Most frequent age presentation: 1st 3 months
of life, 2nd peaks @ 8-10 and in adolescense
• Rapid, regular, usually narrow QRS rhythm,
originating above the ventricles
SVT
Figure 5-42 Supraventricular tachycardia. Note a normal QRS complex
tachycardia at a rate of 214 beats/minute without visible P waves.
SVT
• Paroxysmal, sudden onset & offset
• Rates of SVT vary with age
• Overall average rate for all ages: 235 bpm
– 1st 9 months of life: avg rate is 270 bpm
– Older children: avg rate is 210 bpm( 180-250)
• P waves difficult to define, but 1:1 with QRS
• Important to differentiate from sinus tach
SVT
• Older kids can describe a sensation of a fast
heart rate, palpitations, or chest tightness
• Hemodynamic compromise in newborns and
those with structural heart disease
• Those with typical symptoms would benefit
from cardiac consultation
SVT - Treatment
• Goal: identify unstable patients, differentiate from sinus
tachycardia, and terminate the rhythm
• Vagal maneuvers in stable patients
• Adenosine if IV access readily available
– Stop conduction through AV node
– Helps to define p waves if unsure of etiology
– 0.1 mg/kg (max 6 mg), repeat 0.2 mg/kg ( max 12 mg) in line closest to
central circulation
– Need continuous ECG and BP monitoring
• Synchronized cardioversion
• Amiodarone, Procainamide if above unsuccessful
• Transesophageal atrial pacing can also be performed
V-Tach
• Treatment: IV lidocaine, procainamide,
amiodarone
• If critically ill: synchronized cardioversion
• Long term: meds, ablation, or defibrillator
Ventricular fibrillation
• Seen in children with EKG abnormalities such
as long QT syndrome, or Brugada syndrome
• Cardiomyopathies, structural heart disease
causing ventricular dysfunction
• Treatment: immediate defibrillation, CPR
That’s all!